Hernia: Femoral, Umbilical & Para-umbilical

FEMORAL HERNIA

Anatomy of the Femoral Canal

Path of the Hernia — "Retort Shape"

• The hernia enters the femoral canal at the femoral ring
• Exits superficially through the saphenous opening — situated 1½ inches below and lateral to the pubic tubercle
• Within the femoral canal it is narrow; once through the saphenous opening it expands upward into loose areolar tissue
• This gives it a retort (flask) shape — bulbous end may extend above the inguinal ligament

Epidemiology

• Very rare before age 20; peak incidence >50 years
• More common in women (2:1) — female pelvis is wider, enlarging the femoral canal
• However, even in women, inguinal hernia remains the commonest groin hernia
• Right side affected twice as often as left; bilateral in ~20%
• The femoral canal is a rigid opening → hernia strangulates very frequently
• ~50% present as an emergency with strangulation

Clinical Features / Diagnosis

• Swelling appears below and lateral to the pubic tubercle, below the inguinal ligament
• Often rapidly becomes irreducible with loss of cough impulse due to tight neck
• May be only 1–2 cm — easily mistaken for a lymph node
• As it enlarges, it curves upward and may be confused with a direct inguinal hernia

Differentiating Femoral from Inguinal Hernia

Differential Diagnosis of Femoral Hernia

1. Saphena varix — saccular enlargement of long saphenous vein terminus; disappears on lying down; fluid thrill (not expansile impulse); Schwartz's test positive
2. Enlarged lymph nodes (including gland of Cloquet) — search for infective focus in drainage area
3. Psoas abscess — cold abscess from Pott's disease; lies lateral to femoral artery; cross-fluctuation with iliac part
4. Enlarged psoas bursa — cystic, lies in front of hip joint; diminishes on hip flexion; no cough impulse
5. Femoral aneurysm — expansile pulsation
6. Lipoma
7. Hydrocele of a femoral hernial sac — extremely rare

Treatment — Surgery is Mandatory (No Alternative)

"There is no alternative to surgery for femoral hernia and it is wise to treat such cases with some urgency." — Bailey & Love

1. Low Approach (Lockwood)

• Suitable when no risk of bowel resection; can be done under local anaesthesia
• Transverse incision over hernia → sac opened → contents reduced → sac reduced
• Non-absorbable sutures between inguinal ligament (above) and pectineal ligament (below)
• Caution: abnormal obturator artery branch may lie behind lacunar ligament; protect femoral vein laterally
• Some surgeons use a mesh plug in the defect

2. Inguinal Approach (Lotheissen)

• Incision as for Bassini/Lichtenstein → enter inguinal canal → open transversalis fascia → enter extraperitoneal space
• Hernia lies immediately below → reduced by pulling from above + pushing from below
• Neck closed with sutures/mesh plug; a flat mesh may be laid in the extraperitoneal plane
• Protects against development of concomitant inguinal hernia

3. High Approach (McEvedy / Nyhus modification)

• Ideal for emergency when risk of bowel strangulation is high
• Transverse incision just above inguinal canal at lateral border of rectus → enter preperitoneal space
• Allows generous peritoneal incision for bowel inspection and bowel resection if needed
• Defect closed with sutures or mesh

UMBILICAL & PARA-UMBILICAL HERNIA

Classification

1. Exomphalos (Omphalocele)

• Abdominal contents protrude into the umbilical cord at birth
• Covered by a transparent (diaphanous) membrane
• Congenital/neonatal emergency

2. Congenital Umbilical Hernia

• Hernia through the centre of a congenital weak umbilical scar
• Common in Black infants (incidence up to 8× higher than white infants); up to 10% of all infants
• Appears in first few weeks/months of birth; classic conical shape on crying
• Neck is generally wide → rarely obstructs or strangulates (extremely uncommon <3 years)
• Diagnostic features:
  • Bulge through umbilical scar everting the whole umbilicus
  • Easily reducible (spontaneously reduces when child lies down)
  • Definite impulse on crying
  • Contents usually small intestine → resonant on percussion
• ~90–95% resolve spontaneously within 5 years as umbilical scar thickens and contracts

• Conservative (parental reassurance) under age 2 years if symptomless
• Surgical repair if persists beyond age 2 years
• Surgery: curved infraumbilical incision → sac opened → contents reduced → sac excised → defect closed with interrupted slowly absorbable sutures

3. Acquired (True) Umbilical Hernia

• Occurs in adult life through the umbilical scar itself
• Rare — much less common than paraumbilical hernia
• Almost always due to raised intra-abdominal pressure
• Common causes: pregnancy, ascites, bowel distension, ovarian cyst, fibroid uterus

4. Para-umbilical Hernia

• Commonest acquired umbilical hernia
• Occurs through a defect adjacent to (not through) the umbilicus — usually just above the umbilicus, between the two recti
• The lower half of the fundus of the sac is covered by the umbilicus

• Middle and old age
• Obese women predominantly affected
• Predisposing conditions: obesity, pregnancy, liver cirrhosis with ascites

• Main symptoms: pain and swelling — if small, pain/discomfort may be the only symptom
• Surface smooth, edge distinct (except in very obese patients)
• Bulge typically slightly to one side of the umbilical depression → crescent-shaped appearance
• Contents:
  • Omentum → firm lump
  • Bowel → soft, resonant on percussion
• Many are irreducible when contents become adherent or neck narrows
• If reducible: firm fibrous edge of linea alba defect can be palpated
• The defect is firm and does not enlarge proportionally → causes intermittent abdominal pain
• Strangulation is less common than in femoral hernia, but does occur with the narrow neck

Treatment of Adult Umbilical / Para-umbilical Hernia

Open Repair

• Small defects (<1 cm): simple suture closure (no tension)
• Defects up to 2 cm — Mayo Repair:
  • Transverse incision → sac dissected and opened → contents reduced → peritoneum closed
  • Fascial edges closed in overlapping "waistcoat over trousers" style (superior flap on top) using non-absorbable sutures
• All defects >2 cm: mesh repair — current evidence strongly advises mesh even for small defects due to high recurrence with primary suture alone

Laparoscopic Repair

• Camera port and two working ports placed laterally
• Contents reduced; falciform ligament taken down for mesh surface
• Non-adherent intraperitoneal mesh placed on undersurface of abdominal wall, fixed with tacks/staples/sutures
• Advantages: fewer wound complications, suitable for obese patients, allows large mesh
• Disadvantages: requires expensive tissue-separating mesh; risk of intraperitoneal adhesions, erosion, fistulation

Special Circumstances

• Liver cirrhosis (Child's B/C): very high surgical mortality; careful patient selection; fine continuous sutures to minimise post-op ascites leakage
• Pregnancy: avoid surgery; encourage weight loss, exercise, muscle strengthening; often resolves postpartum

Emergency Repair

• Incarceration, obstruction, strangulation can occur — delay leads to omental/bowel gangrene
• Large hernias may be multiloculated — one loculus may be strangulated while others appear soft
• In established strangulation: no mesh (infection risk) → suture repair only; definitive mesh repair deferred

Key Comparison Summary